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Employment Application

Registered Nurse
LVN
CHHA
MSW
Physical Therapist
Occupational Therapist
Speech Therapist
Others

Personal Information Please write legibly.

Male Female
Yes No

Professional License and Certifications

Licenses, Certifications, and Registrations
Full Time
Part Time
Per Diem
Weekdays
Weekends
Hourly
Others
Yes No
Yes No

Professional Work Experience

Education Attainment

Skills/Training Attended

References

Yes No
Yes No
Yes No
Yes No
Yes No

Applicant's Attestation Statement

I hereby affirm that the Information I have provided in this application are true and correct. I authorize investigation of all statements in this application for employment including references verification, written request for information from previous employer, requirement to supply birth certificate, if necessary, or other proof of authorization to work in the U.S., physical examination as may be necessary in arriving at an employment decision. in the event I have misrepresented or omitted any fact on this application, and Is subsequently hired, I am fully aware that I maybe discharged from the job. I understand ASSIST ON CALL may require physical examination, fingerprinting or background check investigation and TB testing at any time and I agree to such procedures. I agree that the examining physician may disclose to ASSIST ON CALL or its representatives the results of such exams.

l hereby understand and acknowledge that, unless otherwise defined by the applicable law, any employment relationship with this organization is "AT WILL" in nature, which means that the Employer may discharge Employee at any time with or without cause. it is further understood that this "AT WILL" employment may not be changed by any written document or by conduct unless such change is specifically acknowledge in writing by and authorized by an officer of ASSIST ON CALL.

In the event of employment, I understand that any.r false or misleading Information I have provided in my application or interview(s) may result in my immediate termination. I also understand that I am required to abide by all policies and regulations, employment requirements of Assist On Call ASSIST ON CALL, as well as mandated requirements of State and Federal Regulations. Information thereof has been provided and explained to me and I have fully understood all the details thereof as evidenced by my acknowledgement of all the Information attached hereof.

Clear

ASSIST ON CALL does not refuse services to or employment to or in any other way or discriminate against any person on the basis of sex, age, sexual orientation, mental or physical handicap, race, color, religion and ancestry or origin. (Title W of the Civil Rights Act of 1964).